Cases & Commentaries

Admitted to the ICU for COPD exacerbation and atrial fibrillation, a patient who had stabilized is left unattended in the bathroom while the nurse on an understaffed unit attends to a more emergent patient. An assistant later finds the patient on the floor, unresponsive and cyanotic.

Cases & Commentaries

An elderly woman presented to the emergency department following a hip fracture. Although the patient's medication bottles were used to generate a medication list, one of the dosages was transcribed incorrectly. Because the patient then received four times her regular dose, her surgery was delayed due to cardiac side effects.

Cases & Commentaries

Admitted to the hospital with right-hip and left-arm fractures, an elderly woman remained on the same bed from the emergency department for nearly 16 hours and developed a moderate-sized, stage 2 pressure ulcer.

Cases & Commentaries

Admitted to the hospital with community-acquired pneumonia, an elderly man nearly receives dangerous potassium supplementation due to a “critical panic value” call for a low potassium in another patient.

Cases & Commentaries

Following surgical repair for a hip fracture, a nursing home resident with limited mobility developed a fever. She was readmitted to the hospital, where examination revealed a very deep pressure ulcer. Despite maximal efforts, the patient developed septic shock and died.

Cases & Commentaries

Following surgery, a cancer patient was receiving total parenteral nutrition and lipids through a central venous catheter and pain control through an epidural catheter. A nurse mistakenly connected a new bottle of lipids to the epidural tubing rather than the central line, and the error was not noticed for several hours.

Cases & Commentaries

After having a seizure in the emergency department, a woman was to receive intravenous administration of an antiseizure medication. The nurse misread the medication order, gathered 32 vials of the medication, and administered a 10-fold overdose to the patient, who died several minutes later.

Journal Article > Study

An analysis of disciplinary actions of Australian nurses indicated that methods for dealing with deliberate malfeasance were appropriate, but management of honest mistakes did not yet incorporate current thinking on human error management.

Recent guidelines from the Centers for Disease Control and Prevention (CDC) recommend the use of alcohol-based hand sanitizers rather than traditional hand washing. This clinical trial compared these strategies on patient infection rates, nurses' skin conditions, and microbial counts in neonatal intensive care units. Adjusted results showed no difference in patient infection rates or microbial counts, but skin condition was improved using the alcohol-based product. The discussion compares these findings with existing research and the confounding factors associated with measured infection rates. The authors recommend adopting the CDC recommendations as a system-based method to improve hand hygiene practices.

This study describes the development of specific algorithms in clinical anesthesia to address crisis situations. Using the first 4000 reports from the Australian Incident Monitoring Study (AIMS), a team of anesthetists identified a need for 24 algorithms. Investigators created a manual to outline the management approaches and tested it against the incidents from AIMS. The authors conclude that applying these algorithms in daily practice should be considered as decision support when a clinical scenario evolves in an unexpected fashion. This article serves as an introduction to a set of 24 resources that outline structured approaches to crisis management in anesthesia.

Journal Article > Commentary

This commentary discusses the many facets of crisis management in anesthesia care. The authors describe a previously published crisis management algorithm, explain why providers can fail to respond to crises appropriately, and highlight how precompiled responses and algorithms serve as useful aids. They advocate increased team-oriented training, regular review of devised algorithms, and consideration of similar algorithms in other clinical areas to optimize management of crisis situations. This commentary is accompanied by a manual of 24 specific sub-algorithms in anesthesia crisis management.

The authors assess the validity of licensing and accreditation surveys of medication error rates by comparing results to that of an external audit. Independent review teams found a higher rate of error.

Journal Article > Study

The authors of this AHRQ-funded study applied techniques from human factors engineering and observational research to analyze interruptions in the cognitive work of nurses. They found that most interruptions took place during the medication preparation process.

Journal Article > Study

The authors analyzed reports of drug administration errors by nursing students. They found that omission errors were most common and that student inexperience and distraction were contributing factors.